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Get Tx Health Steps Dental Provider Enrollment App 2013-2025
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How to fill out the TX Health Steps Dental Provider Enrollment App online
This guide provides step-by-step instructions on how to complete the TX Health Steps Dental Provider Enrollment Application online. Following these clear and concise steps ensures that your application is accurately filled out and submitted for review.
Follow the steps to complete the application efficiently.
- Click the ‘Get Form’ button to obtain the form and open it in your editor.
- Begin by indicating the type of enrollment you are applying for: new provider, new practice location, or re-enrollment. Select the appropriate box on the form.
- In the 'Requesting Enrollment As' section, select whether you are applying as an individual, group, or performing provider. Make sure your selections align with your provider type.
- Complete Section A, which includes Provider of Service Information. Fill out all applicable demographic and specialty information accurately.
- In Section B, provide the Disclosure of Ownership and Control Interest Statement. Answer all questions, including those related to criminal convictions and ownership interests.
- If applicable, complete the Principal Information Form (PIF-2) for each principal or subcontractor associated with your enrollment.
- For group practices, complete Section C with information about all performing providers. Each provider must also submit a PIF-Dental.
- Complete Sections D, which pertains to the Dental Provider Information Form (PIF-Dental). Ensure all details are filled out.
- Finalize by signing the HHSC Medicaid Provider Agreement, ensuring that original signatures are used. Review all information for accuracy and completeness.
- Attach any required documents as per the checklist provided in the instructions, ensuring that everything is included before submission.
- Save your changes, download the form, or print it out for your records. Ensure all areas are completed before submission.
Complete your enrollment application online today to contribute to the Texas Medicaid program.
To contact AHCCCS provider enrollment, refer to the official AHCCCS website, which contains important contact details and enrollment resources. You can also reach their customer support through the provided phone numbers for specific enrollment assistance. For a smoother experience, consider the TX Health Steps Dental Provider Enrollment App for guidance.
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